A Personalized Self-Management Rehabilitation System for Stroke Survivors: A Quantitative Gait Analysis Using a Smart Insole

Abstract

Background: In the United Kingdom, stroke is the single largest cause of adult disability and results in a cost to the economy of £8.9 billion per annum. Service needs are currently not being met; therefore, initiatives that focus on patient-centered care that promote long-term self-management for chronic conditions should be at the forefront of service redesign. The use of innovative technologies and the ability to apply these effectively to promote behavior change are paramount in meeting the current challenges.

Objective: Our objective was to gain a deeper insight into the impact of innovative technologies in support of home-based, self-managed rehabilitation for stroke survivors. An intervention of daily walks can assist with improving lower limb motor function, and this can be measured by using technology. This paper focuses on assessing the usage of self-management technologies on poststroke survivors while undergoing rehabilitation at home.

Methods: A realist evaluation of a personalized self-management rehabilitation system was undertaken in the homes of stroke survivors (N=5) over a period of approximately two months. Context, mechanisms, and outcomes were developed and explored using theories relating to motor recovery. Participants were encouraged to self-manage their daily walking activity; this was achieved through goal setting and motivational feedback. Gait data were collected and analyzed to produce metrics such as speed, heel strikes, and symmetry. This was achieved using a "smart insole" to facilitate measurement of walking activities in a free-living, nonrestrictive environment.

Results: Initial findings indicated that 4 out of 5 participants performed better during the second half of the evaluation. Performance increase was evident through improved heel strikes on participants' affected limb. Additionally, increase in performance in relation to speed was also evident for all 5 participants. A common strategy emerged across all but one participant as symmetry performance was sacrificed in favor of improved heel strikes. This paper evaluates compliance and intensity of use.

Conclusion: Our findings suggested that 4 out of the 5 participants improved their ability to heel strike on their affected limb. All participants showed improvements in their speed of gait measured in steps per minute with an average increase of 9.8% during the rehabilitation program. Performance in relation to symmetry showed an 8.5% average decline across participants, although 1 participant improved by 4%. Context, mechanism, and outcomes indicated that dual motor learning and compensatory strategies were deployed by the participants.

Keywords: ambulatory monitoring; gait; rehabilitation; self-management; smart insole; stroke.

Figure 1

Technology infrastructure used to support the realist evaluation consisted of touch screen interactive components: (1) a smart insole produced by Tomorrow Options, (2) used to collect gait information, and (3) a server used to analyze data.

Figure 2

Walkinsense device. Top left: force sensitive resistors showing a typical layout configuration; bottom left: the size of a force sensitive resister in relation to a UK 5 pence piece; and right: attachment of devices to lower limb on a manikin.

Figure 3

Time series data showing pressure distribution for a single foot strike.

Figure 4

The average between the first and second half of the realist evaluation for heel strikes on the participants’ affected side starting at day 1.

Figure 5

The average between the first and second half of the realist evaluation for heel strikes on the participants nonaffected side starting at day 1.

Figure 6

The average between the first and second half of the realist evaluation for steps/minute (speed) for all participants starting at day 1.

Figure 7

The average between the first and second half of the realist evaluation of symmetry for all participants starting at day 1.

Figure 8

High level summary information in relation to the length of walk in seconds. With the exception of participant 4, it shows a very gradual decline in intensity of use.

Figure 9

The frequency with which participants used the system irrespective of how intense that use was. This indicates an intention to perform a daily walk. It shows a decline in frequency of use from the first to second half of the realist evaluation.